pro bio tics in oral healthcare-a review

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International Journal of Scientific & Engineering Research, Volume 2, Issue 1, January-2011 ISSN 2229-5518

IJSER 2010

http://www.ijser.org

Probiotics In Oral HealthCare - A ReviewDr. Sumit Narang, Dr. Ruby Gupta, Dr. Anu Narang

Abstract This review focuses on the use of probiotics as preventive and therapeutic products for oral healthcare and thepotential risks associated with dietary probiotics. Probiotics are live microbial food supplements or components of bacteria,

which have been shown to have beneficial effects on human health. Current data suggest that dietary probiotics do not confer amajor risk for oral health.There is a great need to elucidate the role of the oral beneficial microbiota, to identify and conductproper large-scale studies on the usefulness of probiotics to maintain or improve oral health.

Index Termsaging probiotics, oral health, beneficial bacteria, periodontics

INTRODUCTION

The age-old quote by Hippocrates, Let food be

thy medicine and medicine be thy food, is

certainly the tenet of today. The market for

functional foods that promote health beyond

providing basic nutrition, is flourishing. Within

the functional foods, is the small but rapidly

expanding arena of probiotics.1 The term

probiotic is derived from the Greek, meaning

for life are microorganisms proven to exert

health-promoting influences in humans and

animals.2 The Food and Agriculture

Organization of the United Nations (FAO) and

the World Health Organization (WHO) have

stated that there is adequate scientific evidence

to indicate that there is potential for probiotic

foods to provide health benefits and that specific

strains are safe for human use.2 In 1994, the

World Health Organization deemed probiotics to

be the next-most important immune defense

system when commonly prescribed antibiotics

are rendered useless by antibiotic resistance. The

use of probiotics in antibiotic resistance is termed

microbial interference therapy (replacement

therapy or bacteriotherapy) and is sometimes

used interchangeably with probiotics. With

increasing understanding that beneficial

microbes are required for health, probiotics may

become a common therapeutic tool used by

health care practitioners in the not-too-distant

future.3

PROBIOTIC BACKGROUND, CONCEPT

The idea of probiotics dates back to the first

decade of 1900 when the Ukrainian bacteriologist

and Nobel Laureate Ilya Metchnikof (1908)

proposed that lactic acid bacilli may have

beneficial health effects and attributed his own

longevity to regular probiotic ingestion. The

currently used consensus definition of probiotics

was put forward by the World Health

Organization and by the Food and Agriculture

Organization of the United States and officially

adopted by the International Scientific

Association for Probiotics and Prebiotics term

outlining the breadth and scope of probiotics as

they are known today: Live microorganisms

which when administered in adequate amounts

confer a health benefit on the host.4,5,6,7

The term probiotics, the antonym of the term

antibiotics, was introduced in 1965 by Lilly &

Stillwell as substances produced by

microorganisms which promote the growth of

other microorganisms.8

Probiotics are live bacteria that can resist the

rigors of the human digestive system, compete

with pathogens, and that help to improve the gut

flora balance. There are several basic

characteristics of bacteria that may be effective

probiotics. They should be preferably of human

origin, innocuous, able to withstand processing

conditions, and able to survive transit through

the gut and colonize mucosal surfaces. They also

should act against pathogens by means of

multiple mechanisms and elicit minimal

resistance to their effects. The onset of beneficial

effects should be rapid in comparison with the

time required for a vaccine to be fully protective.

Optimally, they should function with or without

antibiotics.9
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COMPOSITION OF PROBIOTICS

Probiotics can be bacteria, moulds, yeast. But

most probiotics are bacteria. Among bacteria,

lactic acid bacteria are more popular.1 Fuller10 in

1989 listed the following organisms as species

used in probiotic preparation: Lactobacillus

bulgaricus, Lactobacillus plantarum,Streptococcus thermophillus, Enterococcus

faecium, Enterococcus faecalis, Bifidobacterium

species, and Escherichia coli. With the exception

of L. bulgaricus and S. Thermophilus, all the

other organisms are all intestinal strains.

A probiotic may be made out of a single bacterial

strain or it may be a consortium as well (may

contain any number up to eight strains). The

advantage of multiple strain preparations is that

they are active against a wide range of conditions

and in a wider range of animal species.1

Probiotics can be in powder form, liquid form,gel, paste, granules or available in the form of

capsules, sachets, etc.

Characteristics of good probiotics

Fuller10 in 1989 listed the following as features

of a good probiotic:

It should be a strain, which is capable of exerting

a beneficial effect on the host animal, e.g.

increased growth or resistance to disease.

It should be non-pathogenic and non-toxic.

It should be present as viable cells, preferably in

large numbers.

It should be capable of surviving and

metabolising in the gut environment e.g.

resistance to low pH and organic acids.

It should be stable and capable of remaining

viable for periods under storage and field

conditions.

Probiotics and general health11

Probiotics have traditionally been used to treat

diseases related to the gastrointestinal tract.

Studies suggest that probiotics may be useful intreatment of patients with hypertension, uro-

genital infections, lactose intolerance, and

elevated levels of cholesterol. Other areas of

application include probiotic effects against

Helicobacter pylori infections in the stomach,

alcoholic liver disease, small bowel bacterial

overgrowth, ulcerative colitis, allergy to milk

protein, juvenile chronic arthritis, antioxidative

effects, asthma, hepatic encephalopathy and their

use as vaccine delivery vehicles.

Probiotic strains in the oral cavity4

An essential requirement for a microorganism to

be an oral probiotic is its ability to adhere to and

colonize surfaces in the oral cavity.Microorganisms generally considered as

probiotics may not have oral cavity as their

inherent habitat and, subsequently, their

possibility to confer benefit on oral health is then

questionable. Studies suggest that lactobacilli as

members of resident oral microflora could play

an important role in the micro-ecological balance

in the oral cavity. The studies further

demonstrated that lactobacilli strains with

probiotic properties may indeed be found in the

oral cavity. Yet there is no evidence whether

these lactobacilli strains were detected due to thefrequent consumption of dairy products leading

to temporary colonization only, or if the oral

environment is their permanent habitat.

Probiotics and periodontal disease8,4,12

The oral microbiota is at least equally as complex

as the gastrointestinal or vaginal microbiota. The

many and varied microbial associations within

the oral cavity include some that appear critical

for maintaining health, according to Socransky.

DNA probe studies of 40 taxa of oral bacteria

obtained from subgingival plaque samples of

healthy individuals and others with periodontal

disease indicate that several bacterial taxa,

including those associated with gingival health,

co-occur in the periodontal crevice.

This group, designated the green cluster,

includes Capnocytophaga species,

Campylobacter concisus, Eubacterium nodatum,

and Streptococcus constellates. Moreover, dental

biofilms are considered to be difficult therapeutic

target. The current view on the etiology of

plaque-related periodontal inflammation

considers three factors that determine whether

disease will develop in a subject: a susceptible

host; the presence of pathogenic species; and the

reduction or absence of so-called beneficial

bacteria. In 1954, a beneficial effect of lactic acid

bacteria on inflammatory infections of the oral

mucosa was reported.5 The presence of

periodontal pathogens could be regulated by

means of antagonistic interactions. A decrease in


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gum bleeding and reduced gingivitis has been

observed by Krasse et al with the application of

L. reuteri. Koll-Klais et al reported that resident

lactobacilli flora inhibits the growth of

Porphyromonas gingivalis and Prevotella

intermedia in 82% and 65%, respectively.

Probiotic strains included in periodontaldressings at optimal concentration of 108 CFU ml

were shown to diminish the number of most

frequently isolated periodontal pathogens:

Bacteroides sp., Actinomyces sp. And S.

intermedius, and also C. albicans. These authors

registered a 10- to 12-month remission period

after periodontal treatment by application of the

periodontal dressing that comprised collagen

and L. casei.

Studies Mohammad S. Al-Zahrani13 have shown

an inverse association between the intake of

dairy products and prevalence of periodontitis.Yoshihiro Shimazaki14 concluded that the

routine intake of lactic acid foods may have a

beneficial effect on periodontal disease.

Candida albicans is among the most common

infectious agents in the oral cavity. The incidence

of yeast infections is higher at older age and

under conditions of impaired immunity. Testing

the pattern of colonization of L. acidophilus and

L. fermentum, Elahi et al showed a rapid decline

in C. albicans in mice after the intake of probiotic

strains. Continuous consumption of probiotics

led to almost undetectable numbers of fungi inthe oral cavity, maintaining the protective effect

for a prolonged period after cessation of

application.

However, there is not yet any true evidence on

the effect of probiotic therapy on periodontal

disease, and the effect of the ingested probiotics

needs further investigation.

Probiotics and dental caries4

The impact of oral administration of probiotics

on dental caries has been studied in several

experiments utilizing different test strains.

Lactobacillus rhamnosus GG and L. casei have

proved their potential to hamper growth of these

oral streptococci. C. Aglar et al registered

definite S. mutans count reduction after a 2-week

consumption of yoghurt containing L. reuteri. A

temporary reduction in S. mutans was observed

during the period of yogurt intake and few days

after cessation of consumption, indicating the

necessity of continual administration of the

probiotic in order to achieve an effect.

Considering the growing body of evidence about

the role of probiotics on caries pathogens,

however, it has been suggested that the operative

approach in caries treatment might be challenged

by probiotic implementation with subsequentless invasive intervention in clinical dentistry.

However, more studies are definitely needed

before this goal could be achieved.

Probiotics and imbalanced oral

ecosystem4,8

Halitosis, the oral malodor, is a condition

normally ascribed to disturbed commensal

microflora equilibrium. It has recently been

positively affected by regular administration of

probiotics. Given that oral microorganisms,

especially those on the tongue, are the primary

cause of halitosis, current treatments focus on the

use of chemical or physical antibacterial regimes

to reduce the numbers of these bacteria.

However, most of these treatments exhibit only a

temporary effect or are associated with

undesirable side-effects when used over a long

period of time.

Kang et al (2006) have shown a definite

inhibitory effect on the production of volatile

sulfur compounds (VSC) by F. nucleatum after

ingestion of Weissella cibaria both in vitro and in

vivo. In children, a marked reduction in the

levels of H2S and CH3SH by approximately

48.2% (P < 0.01) and 59.4% (P < 0.05),

respectively, was registered after gargling with

W. cibaria containing rinse. The possible

mechanism in the VSC reduction is the hydrogen

peroxide generated by W. cibaria that inhibits the

proliferation of F. nucleatum. Streptococcus

salivarius, also a possible candidate for an oral

probiotic, has demonstrated inhibitory effect on

VSC by competing for colonization sites with

species causing an increase in levels of VSC.

However, the few studies published on the role

of probiotics in the treatment of halitosis do not

entitle any evidence-based conclusions.

Safety aspects4,5

The issue of safety is of special concern during

the past few years due to the increased probiotic


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supplementation of different food products.

Probiotics are often regulated as dietary

supplements rather than as pharmaceuticals or

biological products. Thus, there is usually no

requirement to demonstrate safety, purity, or

potency before marketing probiotics. This can

lead to significant inconsistencies between thestated and actual contents of probiotic

preparations, as shown in a recent South African

study.

From the safety point of view, the putative

probiotic microorganisms should not be

pathogenic, should not have any growth-

stimulating effects on bacteria causing diarrhea,

and should not have an ability to transfer

antibiotic resistance genes. The probiotics should

rather be able to maintain genetic stability in oral

microflora (Grajek et al, 2005) The most

important area of concern with probiotic use isthe risk of sepsis. One theoretical concern with

the safety of probiotics is that some have been

designed or chosen to have good adherence to

the intestinal mucosa, and this is considered

important for their mechanism of action.

Adherence to the intestinal mucosa may also

increase bacterial translocation and virulence.

The most potent probiotics, therefore, may have

increased pathogenicity. The relation between

mucosal adhesion and pathogenicity in

Lactobacillus spp. is supported by the finding

that blood culture isolates of Lactobacillus spp.adhere to intestinal mucus in greater numbers

than do isolates from human feces or dairy

products. Lactobacillus bacteremia is a rare

entity, and data on its clinical significance are

mainly found through case reports. For the last

30 years there have been approximately 180

reported cases (Boriello et al, 2003). Clinical

characteristics of Lactobacillus bacteremia are

highly variable, ranging from asymptomatic to

septic shock-like symptoms. Any viable

microorganism is capable of causing bacteremia,

however, especially in patients with severeunderlying diseases or in immunocompromised

state. Nevertheless, the present literature

supports the conclusion that the incidence of

Lactobacillus bacteremia is unsubstantial and

that all the cases where it has been registered are

individuals with other systemic diseases such as

diabetes, cardiovascular diseases,

gastrointestinal disorders, malignancies, or organ

transplant patients. However, it is evident that

careful monitoring is needed in this regard in the

future.

The absence of acquired antibiotic resistances is

another safety criterion to be tested in potential

probiotic candidates. Some probiotics are closely

related to opportunistic bacteria and this mayalso cause transferral of antimicrobial resistance

genes in between microorganisms. Several

results from antibiotic susceptibility tests claim

that the tet(W) and tet(S) genes in some probiotic

lactobacilli and bifidobacteria strains are

responsible for gentamycin, sulfamethoxazole,

polymyxin B, and tetracycline resistance. These

investigations emphasize the need for a minimal

safety evaluation during the selection of strains

for probiotic use.

The way forward2

The use of probiotics in general clinical practice

is not far away. Molecular tools will continue to

be used to understand and manipulate lactic acid

bacteria with a view to producing vaccines and

new and improved probiotic products. The

critical step in wider application will be to make

products available that are safe and clinically

proven in a specific formulation easily accessible

to physicians and consumers. Efforts are needed

to advance the scientific knowledge of probiotics

and determine their mechanisms of action, as

well as describe when and why they fail in

certain situations.

Conclusion

Probiotic agents are living microorganisms

belonging to the normal flora, with low or no

pathogenicity and a positive effect on the health

and well-being of the host. Probiotic therapy

uses bacterial interference and immuno-

modulation in the control of several infectious,

inflammatory, and immunologic conditions.Similar to their better known actions in the

gastrointestinal tract, probiotics exert their effects

in many ways also in the oral cavity. Based on

the currently available clinical data, it seems that

dietary probiotics do not confer a major risk for

oral health. However, the risk of transferring

antibiotic resistance from probiotics to virulent

microorganisms requires more evaluation.


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However data on oral probiotics are yet

insufficient and it is not known whether the

putative probiotic strains could modulate, for

example, immune response in the oral cavity as

has been suggested to take place in the gut

mucosa.

In conclusion, probiotics have made their wayinto oral healthcare and are more likely to be our

friend than our enemy. Despite our rapidly

increasing knowledge of pathogenhost

interactions, the role of beneficial bacteria in

preventing the emergence of pathogenic species

and oral health remains obscure. There is a great

need to elucidate the role of the oral beneficial

microbiota, to identify beneficial bacteria and to

conduct proper large-scale studies on the

usefulness of probiotics to maintain or improve

oral health.

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Probiotics in Health Maintenance and Disease Prevention

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4) JH Meurman, I Stamatova Probiotics: contributions to

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pro bio tics in oral healthcare-a review

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